HomeMy WebLinkAboutR 2013-339 Aging - NC Dept of Insurance for SHIP program $2,579 E�9 -
ORANGE COUNTY—CONTRACT CONTROL SHEET
Routing Order: (1)Department,(2)IT,(3)Risk Management,(4)Financial Services,(5)Attorney,(6)Manager,(7)Clerk
This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager
determines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval. Contracts for
BOCC approval must be submitted through,and complete,the routing process prior to agenda review. Contracts for legal review should
be completed through the legal review process prior to being routed for signature.
Department
Party/Vendor Name: NC Dept of Insurance Party/Vendor Contact Person: R.Van Braxton Contact Phone: 919-807-6900 Party/Vendor
Address: 11 S Boylan Ave City Raleigh State:NC Zip:27603 Department: Aging Amount:$2,579 Purpose: SHIIP(Senior Health
Insurance Information Program Budget Code(s): 10432005-444104 Vendor#N/A (N/A if new vendor) Vendor is a BOCC
consultant? Yes❑No® Contract Type: (Check one)New❑ Renewal® Amendment ❑ Effective Date 07/01/2013 Approved by
Board Yes❑No® Agenda Date: Title of Contract:RO 16998437
If this is a Grant Agreement,pre-application has been approved by the Board of Commissioners Yes❑No❑. If submitted for bid were
bids/RFPs received Yes❑No❑ Bid/RFP number This contract has been reviewed and approved by the Department Director as to
technical content:
Department Director's Signature: Date: J�-ap
IT Director
(Applicable only to hardware/software purchases or related services)This contract has been reviewed and approved by the Information
Technology Director as to technical content and information technology specifications:
IT Director's Signature: Date:
Risk Management
Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No Insurance Required [d Hold
Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown,this contract is approved
by the Risk Manager:
Risk Manager's Signature: V`"°y"`l^' J Date:
-z-%=. elm
Financial Services
This Contract is conditioned upon appropriation by the Board of Commissioners Yes❑No[V A budget amendment is necessary
before approval Yes❑NoIf budget amendment is necessary,please attach to this form. This instrument has been pre-audited in the
manner required by the Local Government Budget and Fiscal Control Act:
3
Financial Services Director's Signature: /). AV— Date: t/ l y t 3
County Attorney
Approval by Board ❑ (Contracts $90,00010 or more for goods or services, $250,000.00 or more for construction, or any BOCC
consultant contract). Approval by Manager (Most other contracts$1,000 and above). Department Director approval only❑ (Under
$1,000). This contract has be n evie a and approved by the Attorney as to legal form and sufficiency:
Attorney's Signature Date: !mil
County Manager
This contract has been reviewed and is approved by the County Manager Yes No❑.
This contract has been reviewed and is for signature by the Ch ' Yes❑No
Manager's Signature: Date:
Clerk to the Board
Approved by BOCC on the day of ,20 . Submitted for Chair signature on the day of ,20
Clerk's Signature: Date:
Revised March 2012